Acute intestinal obstruction caused by the ileum becoming adherent to a lithopedion

REPRINTED FROM

%

GUY’S HOSPITAL REPORTS.

VOL LV.

I

ACUTE INTESTINAL OBSTEUCTION
CAUSED BY THE ILEUM BECOMING
ADHERENT TO A LITHOPBDION.

By J. H. BRYANT, M.D.

I HAVE thought this case worthy of puhlication for two reasons,
firstly on account of the extreme rarity of the occurrence of
a lithopedion, and secondly because, as far as I know, acute
intestinal obstruction from this cause is unique.

A very full account of lithopedions is given in the Bulletin
of the Johns Hopkins Hospital, vol. viii., No. 80, p. 221, by
Dr. J. G. Clark. He reports an interesting example of this con-
dition, and gives a review of the cases hitherto published. He
refers to Kuchenmeister’s table of forty-seven cases reported
between the years 1582 and 1880, and mentions eighteen others
published subsequently, in addition to his own case, in all, a list
of sixty-seven. No mention is made of any of these cases ter-
minating fatally as a result of acute intestinal obstruction from
the intestine becoming adherent to the lithopedion.

In the case recorded below the cause of the intestinal obstruction
was, partly kinking and partly strangulation. A small loop of

208 Acute Intestinal Obstruction Ca^csed by the Ileum

ileum was found to be adherent to the body of the lithopedion in
two places ; through the small aperture thus formed an adjacent
coil of ileum had passed and become strangulated. There was
also considerable kinking of the ileum at the two points where it
was adherent to the body of the lithopedion, and there was

another piece of ileum higher up which was also kinked, on

account of its being adherent to the head of the lithopedion.
The kinking alone was not sufiBcient to account for the acute
symptoms, which must have been caused by the loop of the ileum
becoming strangulated between the adherent loop and the body
of the lithopedion.

The presence of the lithopedion was not suspected during
life. The only possible indication of it was the history
of five months’ amenorrhcea, which had occurred two and

a half years before. There was no previous evidence to

suggest or indicate in any way a ruptured tubal pregnancy.
The hard mass which was felt before and at the time of the
operation was considered to be a malignant growth. It was
unfortunate that the patient’s condition precluded the possibility
of investigating the tumour at the time of the operation, as from
the post-mortem examination, I should say, it would have been
quite possible to have dissected out the lithopedion and to have
completely removed the obstruction. I am indebted to Dr. Perry
for permission to publish the clinical notes and to Dr. Stevens
for his excellent drawing.

Hannah H., 37, was admitted under the care of Dr. Perry, on
November 28th, 1899, for intestinal obstruction (clinical clerk,
E. Cohen). About two and a half years ago she had an attack
of intestinal obstruction which lasted about five days. The
bowels were eventually relieved by enemata. Since then she
had never had any trouble with her bowels and had been quite
well. On Thursday, November 16th, she partook of a big supper,
and after going to bed complained of a pain in her abdomen.
On the next day she was able to get up and do her work. The
bowels were opened on the 17th, but the pain soon afterwards
canje on again, and as it continued, a doctor was called jn.

becoming Adherent to a Lithopedion.

209

Numerous efforts were made to relieve the bowels by means of
purgatives and enemata, but without effect. Mr. Dunn was
asked to see the patient on the 27th, and he advised her
removal to the hospital with a view to laparotomy in order to
find the cause of the obstruction and if possible to remove it.
On November 23rd, she had a bad attack of vomiting which
lasted about twenty-four hours. The vomit had a very foul
odour and she stated that it smelt like a motion. She did
not vomit on the 26th. Two and a half years ago she gave a
history of five months’ amenorrhoea ; before and after the
menstrual disturbance she had always been regular. There
was no history of pain or anaemia, and, as far as she knew, she
had never been pregnant. There was no history of any previous
pelvic trouble.

Condition on admission. — Temperature 99 2°, respiration 24,
pulse 104. She was rather collapsed. Her tongue was dry and
furred. Her eyes were sunken and she had an anxious expression.
She did not appear to be in pain, and was not wasted or cachectic
looking. There was no darkening of the areolae, and there were no
lineae striae on the mammae. She complained of a constant desire
to pass her urine. The abdomen was distended. On palpation,
a hard mass could be felt in the lower part of the abdomen but
extending almost as high as the umbilicus in the median Une.
On the right side it appeared to extend a little higher than the
umbilicus, and it was fairly well defined and was movable. On
percussion, a tympanitic note could be obtained all over the
abdomen except in the right iliac fossa, where there was
dulness. The outline of a distended coil of intestine could
be seen crossing the abdomen just above the umbilicus. No
peristalsis was visible. The heart and lungs appeared to be
normal. The urine was 1020; there was no albumen, sugar or
blood present.

November 28th. She was ordered a milk diet and appeared
very comfortable in bed. At 1 a.m. she became restless and
was given an injection of Morphia gr. and Atropine Sulphate
gr- iTuv. After this she slept for a time and was comfortable.

210 Acute Intestinal Obstruction Caused by the Iletcm

On November 29th she looked worse, and her eyes were sunken.
Pulse 108, respiration 25, temperature 96-2°. A vaginal examina-
tion was made and the cervix was found to be anteverted. On
bimanual examination, a large, undefined, hard mass could be
made out in the hypogastric and lower umbilical region, which
appeared to be fixed to the uterus. Dr. Perry and Mr. Dunn
saw her and an exploratory operation was decided on in order
to determine, and if possible to remove, the cause of the obstruc-
tion. Mr. Dunn made an incision in the median-line of the
abdomen about five inches in length and commencing three
inches above the umbilicus. On opening the peritoneal cavity
the transverse colon was found to be collapsed. He explored
the abdomen with the hand and found a very hard stony-like
mass just above the pubes. It was considered to be a growth
binding down and kinking some coils of small intestine. Owing
to tbe extremely serious condition of the patient it was thought
inadvisable to attempt to remove the hard mass, and so a portion
of the small intestine, which was found to be very distended,
was pulled out, and a Paul’s tube was inserted as near to the
obstruction as possible. The abdomen was then closed, a small
portion of the intestine containing the Paul’s tube being brought
out of the lower part of the wound.

She took the anaesthetic badly, and was very collapsed after-
wards. She did not rally after the operation, and gradually sank
and died at 4 a.m.

I performed the necropsy ten hours after death. There were no
signs of decomposition. Eigor mortis was well marked. There
was an incision about five inches in length in the median line of
the abdomen commencing three inches above tbe umbilicus, the
upper portion of which had been united by gut sutures. A piece
of small intestine in which was situated a Paul’s tube occupied
the lower part of the incision. The lungs and pleurae were normal.
The heart weighed 234 grammes, and was normal in appearance.
The mouth, pharynx, oesophagus and stomach were normal. On
opening the peritoneal cavity the hard mass felt during the opera-
tion proved to be a, lithopedion ; it wa,s situated in the mediap

becoming Adherent to a Lithopedion.

211

line between the pubes and umbilicus, reaching to the level of the
latter. The head was pointing to the left. It was found to be
attached to several coils of small intestine, and also by a few
fibrous adhesions to the uterus and right broad ligament. The
jejunum had been opened about one and a half metres from the
duodenum. A coil of the lower end of the ileum measuring
about 60 centimetres was completely collapsed, it being strangu-
lated by having passed through a small aperture which was
formed by a small portion of the ileum immediately above
having become adherent to the body of the lithopedion in
two places close together. At both points where the gut
was adherent it was sharply kinked, so that the obstruction
was partly due to kinking and partly to strangulation. A little
higher up another piece of the ileum was adherent to the head
of the lithopedion and this was also kinked but not so markedly
as the loop below. The uterus measured 7*5 centimetres in length.
The cevix was nulliparous. There were general pelvic adhesions.
Both Fallopian tubes were found to be running backwards
over the surface of the ovaries and were adherent in Douglas’
pouch. The left ovary was normal in size and appearance.
Attached to the right ovary was a spherical tumour measuring
5 "5 centimetres in diameter ; it was firmly fixed to adjacent parts
by firm fibrous adhesions and it was with diflBculty freed from
these attachments. On section it was reddish brown and
appeared to be made up principally of altered blood. It appeared
to be the remains of the old placenta. Dr. Stevens very
kindly cut some sections and found degenerated chorionic villi
and said the tumour was undoubtedly made up of placental
tissue with blood clot. The lithopedion was found to be lying
almost free in the peritoneal cavity ; there were a few adhesions
attaching it to the uterus and right broad ligament. It was in
a condition of general flexion as if it had been subjected to
much pressure. The head was flexed on the thorax and there
was marked kyphosis. The feet, legs, hands and arms were
fully flexed. The left knee was tucked under the middle of the
right femur, and the right leg was lying across the middle of the

212 Acute Intestinal Obstruction Caused by the Ileum
becoming Adherent to a Lithopedion.

left leg. The arms were placed close to the sides of the thorax.
The head was flattened from side to side. The measurements
were : —

Head — Biparietal diameter ... ... 5'1 cms.

Vertical ... ... ... 5-5 cms.

Antero-posterior ... ... 6-4 cms.

Circumference ... ... 19 cms.

The length of the Body was ... ... 7’5 cms.

,, Femur „ ... ... 4-5 cms.

,, Tibia „ ... ... 4-2 cms.

,, Radius and Ulna was ... 3'5 cms.

,, Humerus „ ... 4 cms.

The measurements of the lithopedion very nearly corresponded
to those of a five months’ fentus.

Acute Intestinal Obstruction, caused by the Ileiivi becoming adherent

to a ^Lithopedion.

Acute intestinal obstruction, caused by the Ileum becoming adherent to a Lithopedion. T. G. Stevens (del.)

I

f

'x

1 4

- >

, ..>'1

- 'i;

*. V

'V

K

4

• J

* .V

> . •

*>r